Which of the following is the drug of choice for Anthrax? - PowerPoint PPT Presentation

Which of the following is the drug of choice for Anthrax?. Furosemide Lasix…a diuretic Aminophyllin respiratory medication Cipro or doxycycline or penicillin Tamoxifen used for estrogen receptor-positive breast tumors.

Copyright Complaint Adult Content Flag as Inappropriate

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

PowerPoint Slideshow about ' Which of the following is the drug of choice for Anthrax?' - jayme-nguyen

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

1. the connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site.

2. the amount of drainage into the chest tube is noted & recorded every 24 hours in the client’s record. Drainage noted and recorded qhr in the 1st 24 hrs then q8 and prn.

3. the suction control chamber has sterile water added every shift & that the system is kept below waist level. Sterile water is added at initial set up and then only as needed (which is rare)

4. the water seal chamber has continuous bubbling and that assessment for crepitus is done once a shift. Continuous bubbling in the sx chamber. Bubbling in the water seal is a sign of an air leak. Assess for Crepitus q8hrs.

4. Position client flat & have him take a deep breath & hold it while the line is disconnected & a new one connected. Increases intrathoracic pressure and so decr possibility that the client will experience an air embolus during the tubing change.

Practice Question 55 connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe?

A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered?

1. Antihistamine

2. Bronchodilator.

3. Decongestant.

4. Expectorant.

Practice Question 55 connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe?

A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered?

Practice Question 56 connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe?

The nurse is monitoring a client who is receiving IV theophylline (aminophylline) for control of an acute episode of his chronic respiratory condition.What nursing observations would cause the nurse the most concern?

Practice Question 5 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Which statement by the client indicates that he understands how to take sublingual nitroglycerin?

1.“If I have a chest pain, I’ll immediately stop what I am doing, sit down, & take the medication.”

2.“I’ll chew 1 tablet then let it dissolve in my mouth if the chest pain last more than 5 minutes. Don’t chew…

3.“I’ll take only 1 dose, & stop what I am doing. If the pain doesn’t stop, I’ll call the doctor.” Take the medication immediately – don’t wait to see if the pain goes away;must also sit or lie down…causes orthostatic hypotension

4.“If I have chest pain, I’ll call the doctor & put 2 tablets under my tongue. Take one tablet, must sit or lie down.

Practice Question 6 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse teaches dietary restrictions to a client with new onset congestive heart failure. Which statement by the client indicates that further teaching is needed?

1.“I’m going to have a ham & cheese sandwich with potato chips for lunch.”

2.”I’m going to weigh myself daily to be sure I don’t gain too much fluid.”

3.”I can have most fresh fruits and fresh vegetables.”

4. “I’m not supposed to eat cold cuts.”

Practice Question 6 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse teaches dietary restrictions to a client with new onset congestive heart failure. Which statement by the client indicates that further teaching is needed?

1.“I’m going to have a ham & cheese sandwich with potato chips for lunch.” need to reduce Na intake – ham, cheese, & chips are high in Na.

2.”I’m going to weigh myself daily to be sure I don’t gain too much fluid.” true

3.”I can have most fresh fruits and fresh vegetables.” true

4. “I’m not supposed to eat cold cuts.” true, high in Na

Practice Question 7 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Which of the cardiac changes if noted on the cardiac monitor would indicate the presence of hypokalemia?

1. Tall, peaked T wave

2. ST segment depression

3. Widening of the QRS complex

4. Prolonged PR interval

Practice Question 7 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Which of the cardiac changes if noted on the cardiac monitor would indicate the presence of hypokalemia?

Practice Question 8 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next?

1.Review the intake and output records for the last 2 days.

2. Change the time of diuretic administration from morning to evening.

3.Request a sodium restriction of 1 g/day from the physician

4. Order daily weights starting on the following morning.

Practice Question 8 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next?

1.Review the intake and output records for the last 2 days.

2. Change the time of diuretic administration from morning to evening. Must complete assessment before beginning interventions…also diuretic adm at night not recommended unless a f/c is in place.

3.Request a sodium restriction of 1 g/day from the physician Must complete assessment before beginning interventions…also

4. Order daily weights starting on the following morning. This is an assessment but #1 would be performed first.

Practice Question 9 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with deep vein thrombosis is receiving a continuous IV infusion of heparin sodium. The client’s aPPT is 65 seconds; the baseline aPTT before initiation of therapy was 30 seconds. A nurse anticipates which action is needed?

1. Shutting off the heparin infusion.

2.Decreasing the rate of the heparin infusion.

3.Leaving the rate of the heparin infusion as is.

4. Increasing the rate of the heparin infusion.

Practice Question 9 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with deep vein thrombosis is receiving a continuous IV infusion of heparin sodium. The client’s aPPT is 65 seconds; the baseline aPTT before initiation of therapy was 30 seconds. A nurse anticipates which action is needed?

4.“I need to sit down and rest if dizziness or light-headedness occurs. can cause orthostatic hypotension

Practice Question 12 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client with acute pulmonary edema. The physician tells the nurse that medication will be prescribed to help reduce preload and afterload. The nurse anticipates that the physician will prescribe which medication?

1. Digoxin (Lanoxin)

2. Nitroprisside sodium (Nipride)

3. Morphine sulfate

4. Furosemide (Lasix)

Practice Question 12 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client with acute pulmonary edema. The physician tells the nurse that medication will be prescribed to help reduce preload and afterload. The nurse anticipates that the physician will prescribe which medication?

Practice Question 13 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client

1. lying on left side with a pillow under the chest wall.

2. lying on right side with a pillow under the head.

3. supine with the head of bed elevated in a 45 to 60 degree angle.

4. supine with slight Trendelenburg position.

Practice Question 13 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client

1. lying on left side with a pillow under the chest wall.

2. lying on right side with a pillow under the head.

3. supine with the head of bed elevated in a 45 to 60 degree angle. Places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac.

4. supine with slight Trendelenburg position.

Practice Question 14 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse has given the client with atrial fibrillation instructions to take one aspirin daily. Which explanation by the nurse is most correct? “This will

1. help prevent clot formation in your heart as a result of your heart rhythm.”

2. prevent any inflammation from occurring on the walls of your heart.”

3. most likely keep you from ever having a heart attack.”

4. keep you from experiencing chest pain.”

Practice Question 14 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse has given the client with atrial fibrillation instructions to take one aspirin daily.Which explanation by the nurse is most correct? “This will

1. help prevent clot formation in your heart as a result of your heart rhythm.”atrial fib puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the effective contraction of the atria.

2. prevent any inflammation from occurring on the walls of your heart.” “any” in the answer eliminates this as a choice. ASA does have anti-inflammatory properties it cannot prevent “any inflammation”.

3. most likely keep you from ever having a heart attack.” not rationale for this therapy.

4. keep you from experiencing chest pain.” low dose ASA does not have analgesic impact.

Practice Question 15 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?

1. Encourage the client to cough and deep breathe.

2. Premedicate the client with prescribed analgesic.

3. Provide the client with a walker.

4. Remove telemetry equipment.

Practice Question 15 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?

1. Encourage the client to cough and deep breathe. will not actively help with endurance.

Practice Question 16 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with cardiac disease turns on his call light and tells the nurse he is experiencing chest pain. What is the first nursing action?

1. Begin oxygen administration at a rate of 4 L/min via a nasal cannula.Angina is the result of an imbalance betw oxygen supply and demand…

2. Listen to heart sounds for ectopic beats.Not indicated

3. Ausculate breath sounds and maintain airway. Not indicated

4. Determine what the client was doing before onset of pain. Could provided significant info – but pt has hx of cardiac disease – angina indicates the need for an intervention to prevent cardiac damage. This intervention is appro after the acute episode has been resolved.

Practice Question 17 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The client who is receiving digoxin (Lanoxin) and furosemide (Lasix) is at risk for developing digitalis toxicity. Which of the following serum lab values would the nurse correlate with this problem?

1. Sodium level of 135 mEq/L

2. BUN of 35 mg/dl

3. Calcium level of 6 mg/dl

4. Potassium level of 3.0 mEq/L

Practice Question 17 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The client who is receiving digoxin (Lanoxin) and furosemide (Lasix) is at risk for developing digitalis toxicity. Which of the following serum lab values would the nurse correlate with this problem?

4. Potassium level of 3.0 mEq/L (3.5-4.1 mEq/L)pt on Digoxin is very sensitive to serum levels of potassium

Practice Question 18 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has developed pulmonary edema secondary to hypertension & CHF. He was experiencing peripheral edema & paroxysmal nocturnal dyspnea prior to admission.The nurse administers Lasix 40 mg IV push. What would the nurse observe as the desired response?

1. Decrease in respiratory rate & in difficulty breathing.

2. BP goes from 160/100 to 150/94.

3. Urine output increases to 100 cc per hour for 3 hours.

4. Peripheral edema begins to decrease in 24 hours.

Practice Question 18 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has developed pulmonary edema secondary to hypertension & CHF. He was experiencing peripheral edema & paroxysmal nocturnal dyspnea prior to admission.The nurse administers Lasix 40 mg IV push. What would the nurse observe as the desired response?

1. Decrease in respiratory rate & in difficulty breathing.Secondary to a decrease in the fluid collecting in the lungs.

2. BP goes from 160/100 to 150/94. Decrease in BP is also a desired response…not the primary desired response.

3. Urine output increases to 100 cc per hour for 3 hours.Increase in u/o desired response also – but the improvement in breathing pattern is the best choice.

4. Peripheral edema begins to decrease in 24 hours. Could also see a decrease in peripheral edema as the circulating blood volume decrease.

Practice Question 19 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse has given instructions to the client with Raynaud’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement if the client states that:

Practice Question 19 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse has given instructions to the client with Raynaud’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement if the client states that:

Smoking cessation is important advised to stop smoking

Sources of caffeine should be eliminated from the diet advised to eliminate caffeine from the diet.

Moving to a warmer climate is needed. Least desirable option. Can avoid exposure to cold via a variety of means. Symptoms could still occur with the use of air conditioning and ruing periods of cooler weather.

Renal postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Practice Question 20 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client’s ability to empty the bladder?

Calculating total fluid intake for the shift.

Measuring post void residual using a bladder scan.

Assisting the client to the bathroom every 2 hours

Recording the amount of the client’s voiding.

Practice Question 20 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client’s ability to empty the bladder?

Calculating total fluid intake for the shift. Does not provide specific info re: the emptying of the bladder.

Measuring post void residual using a bladder scan. “most useful” and “ability to empty the bladder”.

Assisting the client to the bathroom every 2 hours assisting the client to the bathroom and recording intake and output are general interventions that provide estimates of the ability to empty the bladder, but not specific information.

Recording the amount of the client’s voiding. Provides an estimate, but Does not provide specific info re: the emptying of the bladder.

Practice Question 21 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client in the immediate postoperative period after a kidney transplant. What would the nurse anticipate regarding the administration of IV fluid therapy?

1. Infused at a rate of 100 ml/hr to maintain renal perfusion.

2. Fluid administered at a rate to keep blood pressure within a normal range.

3.Amount to be infused would be determined hourly based on urinary output.

Practice Question 21 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client in the immediate postoperative period after a kidney transplant. What would the nurse anticipate regarding the administration of IV fluid therapy?

1. Infused at a rate of 100 ml/hr to maintain renal perfusion. Based on u/o for first 12-24 hrs.

2. Fluid administered at a rate to keep blood pressure within a normal range. Based on u/o for first 12-24 hrs.

3.Amount to be infused would be determined hourly based on urinary output. For the 1st 12-24 hrs.

4. Adequate fluids to maintain clear urine without evidence of blood clots. Notify MD if gross hematuria and clots are noted in the urine…urine may be pink/bloody initially but gradually returns to normal after several days to weeks.

Practice Question 22 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is assisting the client with cystitis with diet selection of an acid-ash diet. The nurse encourages the client to select which of the following foods.?

1. Low-fat milk

2. Baked haddock

3. Garden peas

4. Apples

Practice Question 22 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is assisting the client with cystitis with diet selection of an acid-ash diet. The nurse encourages the client to select which of the following foods.?

Practice Question 25 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?

Whisper a statement while the client blocks both ears

Whisper a statement with the examiner’s back facing the client

Whisper a statement and ask the client to repeat it while blocking one ear.

Stand 4 feet away form the client to ensure that the client can hear at this distance.

Practice Question 25 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?

Whisper a statement while the client blocks both ears not assessing hearing if both ears are blocked.

Whisper a statement with the examiner’s back facing the client

Whisper a statement and ask the client to repeat it while blocking one ear.

Stand 4 feet away form the client to ensure that the client can hear at this distance. Not assessing distance hearing

Practice Question 26 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

Increase sodium in the diet

Avoid sudden head movements

Lie still and watch the television

Increase fluid intake to 3000 ml/day.

Practice Question 26 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

Increase sodium in the diet reduce Na in the diet

Avoid sudden head movements

Lie still and watch the television option could work but would limit mobility/independence…

Increase fluid intake to 3000 ml/day. Fluid restriction is indicated.

Practice Question 27 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Which of the following will facilitate communication with a client who is hearing impaired?

Stand beside the client’s good ear and talk loudly.

Stand behind the client and yell into his good ear.

Face the client and talk loudly.

Face the client and talk in a lowered voice.

Practice Question 27 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Which of the following will facilitate communication with a client who is hearing impaired?

Stand beside the client’s good ear and talk loudly.

Stand behind the client and yell into his good ear.

Face the client and talk loudly.

Face the client and talk in a lowered voice. The client will be better able to hear lower tones – yelling and talking loudly often raises the pitch of the voice and makes it harder to hear.

Practice Question 28 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client who sustained an eye injury arrives at the ER. The initial nursing action would be to

1. flush the eye with sterile saline solution.

2. obtain a history regarding the cause of the injury.

3. place an ice pack on the eye.

4. instill an antibiotic solution.

Practice Question 28 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client who sustained an eye injury arrives at the ER. The initial nursing action would be to

flush the eye with sterile saline solution. Chemical burn

obtain a history regarding the cause of the injury. Must finish the assessment before implemented intervention. Tx of the injury will be dependent on the cause of the injury.

place an ice pack on the eye. contusion

instill an antibiotic solution. Must be prescribed by MD – not usu indicated with an eye injury.

Practice Question 29 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client who had surgery for glaucoma. The nurse tells the client to avoid

1. bending at the waist.

2. reading books with small type.

3. reading books with larger type.

4. watching television.

Practice Question 29 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client who had surgery for glaucoma. The nurse tells the client to avoid

1. bending at the waist. Increases intraocular pressure.

2. reading books with small type.

3. reading books with larger type.

4. watching television.

Avoid activities that increase IOP (intraocular pressure). Reading and watching TV have no impact on IOP.

Practice Question 30 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is developing a teaching plan for the client with chronic glaucoma. Which of the following instructions would the nurse include in the plan?

1. Avoid overuse of the eyes.

2. Decrease fluid intake to control the intraocular pressure.

3. Decrease the amount of salt in the diet.

4. Eye medications will need to be administered lifelong.

Practice Question 30 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is developing a teaching plan for the client with chronic glaucoma. Which of the following instructions would the nurse include in the plan?

1. Avoid overuse of the eyes.

2. Decrease fluid intake to control the intraocular pressure. Minimal impact on the fluid levels in the eye.

3. Decrease the amount of salt in the diet. Minimal impact on the fluid levels in the eye.

4. Eye medications will need to be administered lifelong.

Practice Question 31 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the physician has prescribed atropine sulfate (Isopto-Atropine) and pilocarpine hydrochloride (Isopto-Carpine) eye drops for a client diagnosed with glaucoma. The nurse contacts the physician before the home visit to

1. clarify the order for the atropine sulfate.

2. clarify the order for the pilocarpine hydrochloride.

3. determine the date of the follow-up physician visit.

4. determine the extent of the intraocular pressure.

Practice Question 31 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The home care nurse is reviewing the record of a cline newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the physician has prescribed atropine sulfate (Isopto-Atropine) and pilocarpine hydrochloride (Isopto-Carpine) eye drops for a client diagnosed with glaucoma. The nurse contacts the physician before the home visit to

1. clarify the order for the atropine sulfate. Contraindicated: anticholinergic. Causes vasodilation

2. clarify the order for the pilocarpine hydrochloride. Miotic: reduce intraocular pressure by constricting the pupil and contracting the ciliary muscle.

3. determine the date of the follow-up physician visit. Not necessary unless the pt has need for clarification of this. The nurse can contact MD during/after the visit if needed.

4. determine the extent of the intraocular pressure. Extent of the Intraocular pressure increase is not needed to plan for this pt’s care.

Peripheral iridectomy postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Allows aqueous humor to flow from the posterior to the anterior chamber.

Chronic glaucoma postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Practice Question 32 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client following enoculation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate?

1. Continue to monitor the drainage.

2. Document the finding.

3. Mark the drainage on the dressing and monitor for any increase in bleeding.

4. Notify the physician.

Practice Question 32 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client following enoculation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate?

1. Continue to monitor the drainage. true

2. Document the finding. true

3. Mark the drainage on the dressing and monitor for any increase in bleeding. No pressure over the eye area.

4. Notify the physician. Postop eye surgery always report

1 and 2 are also true – but 4 is best response.

Neurological postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Practice Question 33 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse performing a neurological examination is assessing eye movement. The nurse would perform which of the following to obtain this assessment data?

1. Turn a flashlight on directly in front of the eye and watch for a response.

2. Ask the client to alternate looking straight ahead and then at the examiner’s finger.

3. Instruct the client to look straight ahead and then shine a flashlight into the eye.

4. Ask the client to follow the examiner’s finger through the six cardinal positions of gaze.

Practice Question 33 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse performing a neurological examination is assessing eye movement. The nurse would perform which of the following to obtain this assessment data?

1. Turn a flashlight on directly in front of the eye and watch for a response. Pupil response: reaction to light

2. Ask the client to alternate looking straight ahead and then at the examiner’s finger. Pupil response: accommodation

3. Instruct the client to look straight ahead and then shine a flashlight into the eye. Pupil response: reaction to light

4. Ask the client to follow the examiner’s finger through the six cardinal positions of gaze.

Practice Question 34 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with Parkinson’s disease is taking benztropine mesylate (Cogentin) daily. The nurse tells the spouse to report which side effect of the medication if it occurs?

1. Decreased appetite

2. Inability to urinate.

3. Irregular bowel movements.

4. Shuffling gait.

Practice Question 34 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with Parkinson’s disease is taking benztropine mesylate (Cogentin) daily. The nurse tells the spouse to report which side effect of the medication if it occurs?

1. Decreased appetite

2. Inability to urinate. s/e of med that would need to be addressed by the MD

3. Irregular bowel movements. Can cause constipation

4. Shuffling gait. Sign of Parkinson’s disease

Most common s/e are constipation and urinary retention. Important to initiate preventive measures when the client begins the drug. Med tends to have cumulative effects and the s/e may occur early or after it has been taken for some time. Cogentin enhances mobility by decr tremors.

Practice Question 35 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with myasthenia gravis is taking neostigmine (Prostigmin). The client has frequent exacerbations of myasthenic crisis & cholinergic crisis. The nurse teaches the client that it is important that this medication be

1. double dosed if one dose is missed.

2. taken on an empty stomach.

3. taken on time.

4. titrated for dosage depending on the symptoms.

Practice Question 35 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client with myasthenia gravis is taking neostigmine (Prostigmin). The client has frequent exacerbations of myasthenic crisis & cholinergic crisis. The nurse teaches the client that it is important that this medication be

1. double dosed if one dose is missed. Excessive doses can lead to cholinergic crisis

2. taken on an empty stomach. Adm 30 min before meals with milk and crackers to reduce GI upset.

3. taken on time. Crisis can be caused by inadequ med, fatigue, stress, infection

4. titrated for dosage depending on the symptoms. Not true.

Used to dx myasthenia gravis postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Adm tensilon

Improvement in muscle strength positive for myasthenia gravis

No Improvement in muscle strength negative for myasthenia gravis

Differentiate between myasthenia crisis and cholinergic crisis

myasthenia crisis:

Adm tensilon

Strength improves pt needs more med for s/s MG

cholinergic crisis

Adm tensilon

Weakness more severe too much med for myasthenia gravis

Tensilon Test (med used to tx myasthenia gravis)

Practice Question 36 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has an order to receive valproic acid (Depakene) 250 mg once daily. To maximize the client’s safety, the nurse schedules administration of the medication

1. after breakfast.

2. at bedtime.

3. before breakfast.

4. with lunch.

Practice Question 36 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has an order to receive valproic acid (Depakene) 250 mg once daily. To maximize the client’s safety, the nurse schedules administration of the medication

Practice Question 37 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is planning care for the client with a left hemisphere stroke. The nurse would incorporate in the care plan to place objects

1. within the client’s reach on the right side.

2. within the client’s reach on the left side.

3. just out of the client’s reach on the right side.

4. just out of the client’s reach on the left side

Practice Question 38 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is planning care for the client with a left hemisphere stroke. The nurse would incorporate in the care plan to place objects

1. within the client’s reach on the right side.

2. within the client’s reach on the left side.

3. just out of the client’s reach on the right side.

4. just out of the client’s reach on the left side

Left brain CVA affects motor fx on right side. Place on left side to maintain the pt’s optimal level of independence

Left-brain damage postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Hemiplegia right side

Impaired speech/language (impacts language center as well as motor speech)

Impaired right/left discrimination

Slow performance, cautious

Aware of deficits: depression, anxiety

Impaired comprehension r/t language, math

Practice Question 39 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is providing dietary instructions to a client about the food items that are high in niacin. Which food item is highest in niacin?

1. Milk

2. Potatoes

3. Strawberroes

4. Tomatoes

Practice Question 39 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is providing dietary instrutions to a client about the food items that are high in niacin. Which food item is highest in niacin?

1. Milk dairy, meat, eggs

2. Potatoes

3. Strawberroes

4. Tomatoes

Tomatoes, potatoes, strawberries are high in ascorbic acid (vitamin C)

Practice Question 40 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Acetazolamide (diamox) is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that the primary action of the medication is to

Decrease cerebrospinial fluid production

Maintain an adequate blood pressure for cerebral perfusion

Prevent hyperthermia

Prevent hypertension

Practice Question 40 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Acetazolamide (diamox) is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that the primary action of the medication is to

Decrease cerebrospinial fluid production carbonic anhydrase inhibitor that is used to decr CSF production.

Maintain an adequate blood pressure for cerebral perfusion

Prevent hyperthermia

Prevent hypertension

Note that supratentorial lesion clues the test taker that this is a problem with the brain…preventing incr of ICP is a primary goal for most….

Practice Question 41 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client with trigeminal neuralgia. The client asks for a snack. The nurse determines that the most appropriate choice to meet nutritional needs is

1. Cocoa with honey and toast.

2. Hot herbal tea with graham crackers.

3. Iced coffee and peanut butter crackers.

4. Vanilla wafers and room temperature water.

Practice Question 41 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A nurse is caring for a client with trigeminal neuralgia. The client asks for a snack. The nurse determines that the most appropriate choice to meet nutritional needs is

1. Cocoa with honey and toast. Honey is “thick” and could make chewing more difficult.

Sensory disorder that causes severe facial pain. Mild tactile stimulation of the face can trigger pain.…avoid wind, hot/cold liquids, foods that are mechanically difficult to chew…anything that would cause CNV to spasm and cause the pain.

Practice Question 42 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client is diagnosed with Bell’s palsy. The nurse assessing the client expects to note which of the following?

1. A symmetrical smile.

2. Difficulty closing the eyelid on the affected side.

3. Narrowing of the palpebral fissure on the affected side.

4 Paroxysms of excruciating pain in the lips and cheek on the affected side.

Practice Question 42 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client is diagnosed with Bell’s palsy. The nurse assessing the client expects to note which of the following?

3. On the back with the head of the bed elevated 35-40 °. Choice that most clearly has the HOB higher than 15 degrees. Keep in semi-fowler’s position (on back with HOB elevated) to enhance venous drainage from the cranial vault to asst in preventing the development of incr ICP.

4. Prone with the head of the bed elevated 35°

Practice Question 45 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client who has had a stroke. The nurse has assigned a nursing aide to assist the client with eating. What observation of the aide’s activities would cause the nurse the most concern? The aide

1. Places the client in high-Flower’s position.

2. Is placing the food on the affected side of the mouth.

3. Is talking with the client as she is feeding him.

4. Provides liquids that have been thickened.

Practice Question 45 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

The nurse is caring for a client who has had a stroke. The nurse has assigned a nursing aide to assist the client with eating. What observation of the aide’s activities would cause the nurse the most concern? The aide

1. Places the client in high-Flower’s position.

2. Is placing the food on the affected side of the mouth. Place on unaffected side of mouth

3. Is talking with the client as she is feeding him.

4. Provides liquids that have been thickened.

Musculoskeletal System postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Practice Question 46 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

After fitting a client with crutches the nurse is assessing to determine if they fit properly. What observation would cause the nurse the most concern?

1. When the client is standing, with the hands placed on the hand supports, the arms are straight.

2.There is space of about 1 1/2 to 2 inches between the axillary fold and the top of the crutch.

3. The client can place crutches about 6-8 inches lateral to the to the foot when walking.

4. The arms are flexed about 30° and resting on the hand supports when the client is standing.

Practice Question 46 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

After fitting a client with crutches the nurse is assessing to determine if they fit properly. What observation would cause the nurse the most concern?

1. When the client is standing, with the hands placed on the hand supports, the arms are straight. Elbows should be slightly flexed.

2.There is space of about 1 1/2 to 2 inches between the axillary fold and the top of the crutch. 2 finger breadth

3. The client can place crutches about 6-8 inches lateral to the to the foot when walking. correct

4. The arms are flexed about 30° and resting on the hand supports when the client is standing. Allows for wt bearing on the hand supports and not under the arm when the client begins to walk.

Practice Question 47 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Postoperatively, following a lumbar laminectomy, the client complains of the same low back pain as before surgery. The nurse knows that this is caused by what problem?

1. Failure of the surgery to remove the herniated disk.

2. Limitation of movement from spinal fusion.

3. Swelling of the operative area that compresses adjacent structures.

4. Twisting of the spine when turning side to side.

Practice Question 47 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

Postoperatively, following a lumbar laminectomy, the client complains of the same low back pain as before surgery. The nurse knows that this is caused by what problem?

1. Failure of the surgery to remove the herniated disk.

2. Limitation of movement from spinal fusion. Limitation of movement will decr pain.

3. Swelling of the operative area that compresses adjacent structures. After surgery edema may cause compression of structure in the operative area. This results in similar pain as experienced by pt preop.

4. Twisting of the spine when turning side to side. Twisting will cause pain – but it is usu a different pain than the pain preop.

Practice Question 48 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has a long leg plaster cast applied. What nursing actions are implemented while the cast is still wet?

1. Keep the client and cast covered with blankets.

2. Place a heat lamp directly over the cast.

3. Support the cast on plastic-covered pillows.

4. Use only the fingertips when moving the cast.

Practice Question 48 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has a long leg plaster cast applied. What nursing actions are implemented while the cast is still wet?

1. Keep the client and cast covered with blankets. Covering the cast with blankets will not promote drying.

2. Place a heat lamp directly over the cast. Do not apply heat to damp cast.

3. Support the cast on plastic-covered pillows. Support the cast on a pillow that will not absorb the moisture.

4. Use only the fingertips when moving the cast. Palms of hands used to turn client.

Practice Question 49 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has a fractured hip and is currently in Buck’s traction awaiting surgery. How is the countertraction achieved in Buck’s traction for a fractured hip?

1. Applying a 10-pound counterweight at the knee.

2. Elevating the foot of the bed frame and allowing the weights to hang freely.

3. Elevating the knee gatch and elevating the head of the bed about 30°.

4. Placing shock blocks under the head of the bed.

Practice Question 49 postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client?

A client has a fractured hip and is currently in Buck’s traction awaiting surgery. How is the countertraction achieved in Buck’s traction for a fractured hip?

1. Applying a 10-pound counterweight at the knee.

2. Elevating the foot of the bed frame and allowing the weights to hang freely.

3. Elevating the knee gatch and elevating the head of the bed about 30°.

4. Placing shock blocks under the head of the bed.

For any client in traction, a nsg priority is to determine the correct amt of wt and to assess for effectiveness of countertraction. Wts must hang freely for countertraction to be effective. In Buck’s traction the entire foot of the bed is elevated to prevent the client from moving toward the end of the bed.

Buck’s Traction the correct amt of wt and to assess for effectiveness of countertraction. Wts

2. Avoid NSAIDS to prevent bleeding. Use NSAIDS to tx pain and inflammation

3. Plan activities that use ROM in extremities.Must keep joints mobilized because of the invasion of the lupus erythematosus cells into the joints. Pace activities to conserve energy – need to maintain ROM

4. Pregnancy is contraindicated. Creates extra stress on body but is OK. Should be advised re: progress of her disease and implications fro pregnancy – but can carry and deliver healthy infant.

The nurse is caring for a client who is categorized as HIV+, Category A. What would the nurse anticipate finding on the nursing assessment?

1. Confusion, disorientation, loss of coordination. Not asso with category A

2. Dyspnea, tachycardia on exertion, fever. Not asso with category A

3. Fatigue, weight loss, night sweats. Category A is when the primary condition is identified or the client has recently been infected. May be asymptomatic or may have symptoms of early nonspecific changes.

4. Red, raised lesions on neck and face, fever. Not asso with category A

A child has chicken pox. What type immunity will this child have on his recovery?

Actively acquired immunity injection of human or animal serum

Artificially acquired immunity immunizations

Natural passive immunity placental transfer

Naturally acquired active immunity a child who contracts chicken pox for the first time develops antibodies during the period of infection. These antibodies cerate a naturally acquired, lifelong type of active immunity.

The nurse is caring for a client who is experiencing a severe anaphylactic reaction to penicillin. After beginning oxygen administration and determining that vital signs, including respiration are adequate, the next most important nursing action would be to:

The nurse is caring for a client who is experiencing a severe anaphylactic reaction to penicillin. After beginning oxygen administration and determining that vital signs, including respiration are adequate, the next most important nursing action would be to:

Administer analgesics to reliever the pain should be not pain

Start an IV for fluid administration Shock is a common problem in anaphylactic reactions. Important to establish an IV for fluid and med administration.

Insert a catheter to determine urinary output no reason client cannot void on his own.

Obtain a history of possible reactions to penicillin. History important but can be addressed later.

Extra Adult Health the correct amt of wt and to assess for effectiveness of countertraction. Wts

A client returning to the unit following cardiac catheterization has a stat order to receive a dose of procainamide (Pronestyl). The nurse uses which equipment to determine most adequately the client’s response to the medication?

A client returning to the unit following cardiac catheterization has a stat order to receive a dose of Procainamide (Pronestyl). The nurse uses which equipment to determine most adequately the client’s response to the medication?

1. Cardiac monitor used to tx ventricular dysrythmias. Procainamide is an antidysrhythmic.

2. Glucometer not indicated

3. Noninvasive blood pressure cuff good to have as an improvement in rhythm would improve CO and BP…not best choice.

4. Pulse oximeter…good to have as this provides general info about the client’s cardiovascular status…not best choice.

A client with a myocardial infarction calls the nurse because he is experiencing chest pain. The nurse administers a sublingual nitroglycerin.The chest pain is unrelieved. The next nursing action is which of the following?

A client with a myocardial infarction calls the nurse because he is experiencing chest pain. The nurse administers a sublingual nitroglycerin.The chest pain is unrelieved. The next nursing action is which of the following?

1. Administer another nitroglycerin tablet. Adm one tablet q5min times three for chest pain if SBP is 100 or greater.

2. Increase the flow rate of the oxygen. If prescribed by MD this would be next action

3. Contact the physician. If 3 NTG tablets do not relieve the pain contact the MD.

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Diilantin). Which statement make by the client indicates understanding about this medication? “I should

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Diilantin). Which statement make by the client indicates understanding about this medication? “I should

1. take my medication before having a blood level drawn.” take med as prescribed by MD.

2. adjust my dose depending of the severity of the side effects.” Never adjust dose of any med without consulting MD

Extra Practice 10 the correct amt of wt and to assess for effectiveness of countertraction. Wts

A client comes into the ER; he states that he had a kidney transplant a month ago. What symptoms would cause the nurse the most concern?

1. Fever, increased blood pressure, and increased fatigue.

2. Inflamed joints and pitting edema in lower extremities.

3. Nausea, vomiting and diarrhea for the past 6 hours.

4. Urine dark with a specific gravity of 1.025.

Extra Practice 10 the correct amt of wt and to assess for effectiveness of countertraction. Wts

A client comes into the ER; he states that he had a kidney transplant a month ago. What symptoms would cause the nurse the most concern?

1. Fever, increased blood pressure, and increased fatigue. Fever and fatigue are the most freq. early symptom of acute rejection.

2. Inflamed joints and pitting edema in lower extremities. Pitting edema is not common – esp in the early stages of rejection.

3. Nausea, vomiting and diarrhea for the past 6 hours. Not asso with early stages of rejection

4. Urine dark with a specific gravity of 1.025. Indicates that the kidneys are able to concentrate urine – normal.

Extra Practice 11 the correct amt of wt and to assess for effectiveness of countertraction. Wts

A client with a diagnosis of AID’S has developed Pneumocystis carnii pneumonia (PCP). What will be important for the nurse to include in the nursing care plan?

1. Explain to the client why he cannot go outside his room.

2. Put a mask on the client whenever he has visitors in his room.

3. Wear a mask and gown when providing direct care to the client.

4. Wear a gown and gloves when assisting client with personal hygiene.

Extra Practice 11 the correct amt of wt and to assess for effectiveness of countertraction. Wts

A client with a diagnosis of AID’S has developed Pneumocystis carnii pneumonia (PCP). What will be important for the nurse to include in the nursing care plan?

1. Explain to the client why he cannot go outside his room.

2. Put a mask on the client whenever he has visitors in his room.

3. Wear a mask and gown when providing direct care to the client.

4. Wear a gown and gloves when assisting client with personal hygiene. Not transmitted person to person. Do not need airborne or droplet precautions but standard precautions must be strictly adhered to.